Information Collection

Authorization for Release of Employment Information Form

IC 182800 under ICR 201609-0915-006 · OMB 0915-0140.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0140 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Authorization for Release of Employment Information Form	Form
2 Authorization to Release Employment Information Form NCLRP - Authorization to Release Employment Information.pdf	Form

IC Title:

Authorization for Release of Employment Information Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR Part 57 Section 312 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2	Authorization to Release Employment Information Form	NCLRP - Authorization to Release Employment Information.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Public Health Service and National Health Service Corps Scholarship/Loan Repayment Participants Records System

FR Citation: 58 FR 12968

Number of Respondents: 5,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5,500	5,500
Annual IC Time Burden (Hours)	550	550
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.